Logo American Journal of Case Reports

Call: 1.631.629.4328
Closed: National Holiday

Contact Us

Logo American Journal of Case Reports Logo American Journal of Case Reports Logo American Journal of Case Reports

11 July 2020: Articles  USA

and Parainfluenza Virus Pneumonia in a Patient with AIDS

Unusual or unexpected effect of treatment, Rare disease, Rare coexistence of disease or pathology

Sandhya Nagarakanti1ABCDEF*, Eliahu Bishburg1ABCDEF

DOI: 10.12659/AJCR.923132

Am J Case Rep 2020; 21:e923132



BACKGROUND: Parainfluenza viruses (PIV) are known to cause mild respiratory tract infections in immunocompetent patients but can cause severe infections in immune-compromised patients such as transplant recipients and children with HIV. PIV infection in HIV-infected adults has rarely been reported. We report a case of PIV pneumonia in an adult with AIDS who was successfully treated with oral ribavirin.

CASE REPORT: A 64-year-old man with history of acquired immune deficiency syndrome (AIDS) was admitted to the hospital with shortness of breath that began 3 days before. He was in respiratory distress and required mechanical ventilation on arrival. A bronchoalveolar lavage (BAL) culture was positive for Hemophilus influenzae and a respiratory viral panel was positive for Parainfluenza virus. The patient was initially started on Cefepime and Trimethoprim- Sulfamethoxazole and later changed to Ceftriaxone based on culture results. As the patient’s condition did not improve after 48 h, oral ribavirin was added to treat PIV. The patient subsequently improved and was extubated after 72 h.

CONCLUSIONS: Oral ribavirin can have a beneficial effect in AIDS patients who have PIV-associated pneumonia. Further investigation of the benefit of oral ribavirin in similar cases is warranted.

Keywords: Haemophilus Infections, HIV, Parainfluenza Virus 1, Human, Parainfluenza Virus 2, Human, Parainfluenza Virus 3, Human, ribavirin, Acquired Immunodeficiency Syndrome, Anti-Bacterial Agents, Antiviral Agents, Ceftriaxone, coinfection, Haemophilus influenzae, Paramyxoviridae Infections, Pneumonia, Viral, Respiration, Artificial, respiratory distress syndrome


Parainfluenza virus (PIV) is single-stranded, enveloped RNA virus causing respiratory infections in children and adults. PIV are known to cause severe infections in immune-compromised patients such as transplant recipients and children with HIV. Haemophilus influenzae (H. influenzae) is a frequent cause of bacterial pneumonia in HIV-infected people and is also known to be colonizer in chronic obstructive pulmonary disease (COPD) patients, causing challenges in distinguishing between true infections vs. colonization in patients with HIV and COPD. PIV infection in HIV-infected adults has rarely been reported. There are no approved treatment options to treat PIV infections.

Case Report

A 64-year-old man was admitted with shortness of breath for 3 days prior to admission. The patient’s history was significant for acquired immune deficiency syndrome (AIDS), with a CD4 of 34 µL; he was maintained on antiretroviral therapy with abacavir/lamivudine and dolutegravir. The patient had a history of COPD and renal insufficiency. On admission, his temperature was 97.4°F (36.3°C), blood pressure 114/68 mmHg, heart rate 94 beats/min, and respiratory rate 20/min. A cardiac examination revealed normal heart sounds. His lungs were clear to auscultation, with bilateral rhonchi. The abdomen was soft, with no organomegaly. Results of a neurological exam were normal.

A laboratory examination revealed a white blood cell (WBC) count of 14.2×103/µL, hemoglobin 13.8 g/dL, platelets 268×103/µL, sodium 140 mmol/L, blood urea nitrogen 14 mg/dL, creatinine, 0.73 mg/dL, procalcitonin 6.43 ng/mL, and serum LDH 306 Unit/L. A urine drug toxicity study was positive for benzodiazepines and cocaine. Arterial blood gas showed a pH of 7.17, PCO2 92 mmHg, PO2 58 mmHg, oxygen saturation of 81%, CD4 37cells/µL (6%), and HIV viral load 32 copies/ml. A chest X-ray showed bilateral lung consolidations without effusion or pneumothorax, and a CT chest showed extensive diffuse bilateral interstitial opacities with multifocal areas of consolidation, most prominent in the right lower lobe, compatible with multifocal pneumonia and pulmonary arterial hypertension (Figures 1, 2).

In the emergency room, the patient was in respiratory distress, and because of his diagnosis of COPD, he was given intravenous solumedrol 125 mg and albuterol nebulizer treatment and was placed on BiPAP. His clinical condition worsened; he was intubated and required mechanical ventilation, and then was transferred to the Intensive Care Unit. The diagnoses of Pneumocystis jirovecii pneumonia (PJP) vs. community-acquired pneumonia were considered. The patient was placed on IV trimethoprim/sulfamethoxazole 450 mg q6hrs (trimethoprim dose) and cefepime 2 gm Q 12hrs. Serum beta D glucan was <31 pg/mL. The patient underwent bronchoalveolar lavage (BAL), which revealed a WBC count of 19 800 CU/MM with 92% neutrophils and RBC 4478 CU/MM. The respiratory virus panel from BAL using target-enriched multiplex polymerase chain reaction (PCR) assay (BioMérieux easy MAG, Life Tech Veriti, Sensovation Sensospot) was positive for PIV, and BAL culture grew Hemophilus influenzae (H. influenzae). Cytology from BAL showed rare pulmonary alveolar macrophages in a background of purulent exudate. No Pneumocystis, fungal organisms, or viral inclusions were seen on Papanicolaou and Gomori methenamine-silver stains. Intravenous Ceftriaxone 1 gram every 24 h was initiated and cefepime and trimethoprim-sulfamethoxazole were discontinued. The patient’s clinical condition did not improve and he remained intubated, requiring mechanical ventilation. Due to the finding of PIV on BAL, a decision was made to start oral ribavirin 600 mg every 12 h.

The patient improved clinically over the next 48 h after starting ribavirin and he was extubated after 72 h. A chest X-ray after 7 days of treatment with ribavirin showed improving bibasilar opacities, and the patient was discharged home and continued to do well. A follow-up CT scan done 30 days after discharge revealed significantly decreased bilateral interstitial opacities (Figure 3).


PIV is an enveloped, single-stranded, negative-sense RNA virus belonging to the genus Paramyxoviridae. The PIV are distributed worldwide and are important respiratory pathogens in adults and children. There are 4 known PIV serotypes: 1–4. PIV 1–3 are implicated in most infections, both in children and adults, whereas serotype 4 is less common [1].

Host defense against PIV is mediated by both humoral and cellular immunity. Antibodies against the 2 main viral surface glycoproteins, F and HN, are neutralizing. Secretory IgA develops after natural infection, while cytotoxic T lymphocytes have been shown to have a role in clearance of PIV in hamster and mouse models [1].

PIV can cause severe clinical syndromes in immunocompromised hosts; children with severe combined immunodeficiency syndrome (SCID) were described with giant cell pneumonia, and with a fulminant course [2]. Infections have been described in inpatients who underwent bone marrow and lung transplant. Most of these infections start with an initial upper-respiratory tract infection (URI) which progresses to become a lower-respiratory tract infection (LRTI), progressing to pneumonitis and often leading to respiratory failure [3–5]. Progression from URI to LRTI was described in 18–77% of immunosuppressed patients [5–7]. Srinivasan et al. [8] noted that PIV infection was the most commonly encountered symptomatic respiratory viral infection. Risk factors for PIV progression to LRTI were thought to be lymphopenia, steroid use, and co-infections with other respiratory agents [9]. The virus has also been implicated in COPD exacerbation [10].

The natural history of PIV infection in HIV-infected children is not well characterized, but it seems that severe disease does not appear until they develop significant T cell depletion [11,12].

Cohen et al. [13] studied the incidence of PIV pneumonia and found that it was higher in HIV-infected children and adults compared to the HIV non-infected population. Madhi et al. prospectively studied the clinical manifestations of 80 hospitalized children with severe respiratory tract infection caused by PIV and noted that the clinical features were similar between HIV-infected and non-infected children [14]. HIV-infected children with PIV had increased rates of hospitalization and increased morbidity [3,4,14].

Garbino et al. [15] screened 59 BAL samples from HIV-infected patients suspected of having an opportunistic infection by using real-time reverse transcriptase PCR assays, finding that 11 samples had at least 1 respiratory virus, and 3 were found to have 1 each of the PIV serotypes 2, 3, and 4.

Other viral infections can mimic PIV infection. Cunha et al. described a patient diagnosed as having PIV; the patient presented with influenza-like illness but with negative rapid influenza diagnostic tests. A viral respiratory fluorescent antigen panel and reverse transcriptase PCR for influenza (H1N1) were negative [16]. Another case report described an adult HIV-infected patient who was hospitalized with influenza-like illness suspected of having influenza and PCP pneumonia. The patient was eventually diagnosed as having RSV pneumonia [17].

H. influenzae is a frequent cause of bacterial pneumonia in HIV-infected patients, with an incidence of 15–27% [18]. Invasive disease with this pathogen has been described to be 100-fold higher in HIV-infected patients than in non-infected patients [18]. Caiaffia et al. noted that CD4 lymphocyte count less than 200 µL, previous episode of PJP, age 30–40 years, and smoking illicit drugs were associated with higher incidence of bacterial pneumonia in HIV-infected patients [19].

H. influenzae is a frequent colonizer in COPD patients’ airways and has been implicated as a cause of intermittent exacerbations [20,21].

Currently there are no FDA-approved treatments for PIV. Ribavirin is active against Paramyxoviruses through the depletion of intracellular guanosine triphosphate pools secondary to inhibition of inosine monophosphate dehydrogenase. Aerosolized ribavirin has been tried, but it is costly and causes many aerosol-related adverse effects, including bronchospasm and teratogenic effects on health care workers [22]. In addition, the administration of aerosolized ribavirin through a ventilator can crystallize in the ventilator circuit. The alternative intravenous ribavirin is not currently approved for use in the USA.

Oral ribavirin has been suggested as an option for treatment of patients with PIV and RSV infections. The drug has shown favorable results in some small case series and case reports. The benefit of using oral ribavirin has been described in children with HSCT and lung transplant recipients, and both RSV and PIV infections were included in these series [3,23,24]. However, it is difficult to draw a conclusion about the benefit of oral ribavirin, as these reports did not have a comparator treatment arm. In a study by So-Youn Park et al. [25], the authors compared oral ribavirin-treated patients with hematological diseases to patients receiving only supportive care. The authors used a propensity-matched case control analysis and logistic regression with co-variable adjustments in order to compensate for biases inherent in observational studies. The authors concluded that oral ribavirin was not associated with better outcome than supportive care [25]. To the best of our knowledge, there are no published case reports of PIV infection in AIDS patients who were successfully treated with oral ribavirin.

In summary, our patient was initially diagnosed and treated as having COPD exacerbation. When his respiratory condition deteriorated, he was considered to have PJP and was treated with trimethoprim/sulfamethoxazole, but this diagnosis was later ruled out. BAL culture showed H. influenzae, and respiratory panel PCR was positive for PIV. The patient was initially treated with ceftriaxone, but when no improvement was noted, oral ribavirin was initiated, with a significant clinical improvement, allowing extubation and eventual discharge home.

To the best of our knowledge, this is the first published case in which both H. influenzae and PIV were isolated from an AIDS patient who had a significant improvement after treatment with oral ribavirin.


PIV can cause of severe clinical syndromes in immunocompromised hosts and can lead to fulminant pneumonia in this population. There are no FDA-approved therapies for PIV pneumonia. Oral ribavirin may have a beneficial effect in AIDS patients who have PIV-associated pneumonia by the associated decreasing morbidity and mortality. Further investigation of the benefit of oral ribavirin in similar cases is warranted.


1.. Hendrickson KJ, Parainfluenza viruses: Clin Micro Rev, 2003; 16(2); 242-64

2.. Jarvis WR, Middleton PJ, Gelfand EW, Parainfluenza pneumonia in severe combined immunodeficiency disease: J Pediatr, 1979; 94(3); 423-25

3.. Wendt CH, Weisdorf DJ, Jordan MC, Parainfluenza virus respiratory infection after bone marrow transplantation: N Engl J Med, 1992; 326(14); 921-26

4.. Apalsch AM, Green M, Ledesma-Medina J, Parainfluenza and influenza virus infections in pediatric organ transplant recipients: Clin Infect Dis, 1995; 20(2); 394-99

5.. Lewis VA, Champlin R, Englund J, Respiratory disease due to parainfluenza virus in adult bone marrow transplant recipients: Clin Infect Dis, 1996; 23(5); 1033-37

6.. Wendt CH, Fox JM, Hertz MI, Paramyxovirus infection in lung transplant recipients: J Heart Lung Transplant, 1995; 14(3); 479-85

7.. Hodson A, Kasliwal M, Streetly M, A parainfluenza-3 outbreak in a SCT unit: Sepsis with multi-organ failure and multiple co-pathogens are associated with increased mortality: Bone Marrow Transplant, 2011; 46(12); 1545-50

8.. Srinivasan A, Wang C, Yang J, Symptomatic parainfluenza virus infections in children undergoing hematopoietic stem cell transplantation: Biol Blood Marrow Transplant, 2011; 17(10); 1520-27

9.. Seo S, Xie H, Karron RA, Parainfluenza virus type 3 Ab in allogeneic hematopoietic cell transplant recipients: Factors influencing post-transplant Ab titers and associated outcomes: Bone Marrow Transplantation, 2014; 49; 1205-11

10.. Branche AR, Falsey AR, Parainfluenza virus infection: Semin Respir Crit Care Med, 2016; 37; 538-54

11.. Josephs S, Kim HW, Brandt CD, Parrott RH, Parainfluenza 3 virus and other common respiratory pathogens in children with human immunodeficiency virus infection: Pediatr Infect Dis J, 1988; 7(3); 207-9

12.. McSherry GD, Human Immunodeficiency virus-related pulmonary infections in children: Semin Resp Infect, 1996; 11; 173-83

13.. Cohen AL, Sahr PK, Treurnicht F, Parainfluenza virus infection among human immunodeficiency virus (HIV)-infected and HIV-uninfected children and adults hospitalized for severe acute respiratory illness in South Africa, 2009–2014: Open Forum Infect Dis, 2015; 2(4); ofv139

14.. Madhi SA, Ramasamy N, Petersen K, Severe lower respiratory tract infections associated with human parainfluenza viruses 1–3 in children infected and non-infected with HIV type 1: Eur J Clin Microbiol Infect Dis, 2002; 21(7); 499-505

15.. Garbino J, Inoubli S, Mossdorf E, Swiss HIV Cohort Study. Respiratory viruses in HIV-infected patients with suspected respiratory opportunistic infection: AIDS, 2008; 22(6); 701-5

16.. Cunha BA, Corbett M, Mickail N, Human parainfluenza virus type 3 (HPIV 3) viral community-acquired pneumonia (CAP) mimicking swine influenza (H1N1) during the swine flu pandemic: Heart Lung, 2011; 40(1); 76-80

17.. Cunha BA, Syed U, Hage JE: Heart Lung, 2012; 41(1); 76-82

18.. Steinhart R, Reingold AL, Taylor F: JAMA, 1992; 268(23); 3350-52

19.. Caiaffa WT, Vlahov D, Graham NM: Am J Respir Crit Care Med, 1994; 150(6 Pt 1); 1493-98

20.. Murphy TF, Brauer AL, Schiffmacher AT, Sethi S: Am J Respir Crit Care Med, 2004; 170(3); 266-72

21.. Smith CB, Golden CA, Kanner RE, Renzetti AD: Lancet, 1976; 1(7972); 1253-55

22.. Nichols WG, Peck Campbell AJ, Boeckh M, Respiratory viruses other than influenza virus: Impact and therapeutic advances: Clin Microbiol Rev, 2008; 21; 274-90

23.. Dreyzin A, Michaels MG, Vander Lugt MT, Szabolcs P, Oral ribavirin for paramyxovirus infection after alemtuzumab-containing reduced-intensity conditioning HCT regimen: Pediatr Transplant, 2019; 23(2); e13358

24.. Pelaez A, Lyon GM, Force SD, Efficacy of oral ribavirin in lung transplant patients with respiratory syncytial virus lower respiratory tract infection: J Heart Lung Transplant, 2009; 28; 67-71

25.. Park SY, Baek S, Lee SO, Efficacy of oral ribavirin in hematologic disease patients with paramyxovirus infection: Analytic strategy using propensity score: Antimicrob Agents Chemother, 2013; 57(2); 983-89

In Press

Case report  Congo, the Democratic Republic of the

A Rare Case of Hyperglycemia, Ketoacidosis, and Central Facial Paralysis in a Newly-Diagnosed Diabetic Woman

Am J Case Rep In Press; DOI: 10.12659/AJCR.942425  

Case report  China (mainland)

Intracranial Parasitic Fetus in a Living Infant: A Case Study with Surgical Intervention and Prognosis Anal...

Am J Case Rep In Press; DOI: 10.12659/AJCR.944371  

Case report  Jordan

Blue Toe Syndrome in Behçet’s Disease: A Case Report

Am J Case Rep In Press; DOI: 10.12659/AJCR.943813  

Case report  South Korea

A Rare Case of Stroke in a 76-Year-Old Woman: Left Atrial Papillary Fibroelastoma as the Culprit

Am J Case Rep In Press; DOI: 10.12659/AJCR.943568  

Most Viewed Current Articles

07 Mar 2024 : Case report  USA 38,232

Neurocysticercosis Presenting as Migraine in the United States

DOI :10.12659/AJCR.943133

Am J Case Rep 2024; 25:e943133


10 Jan 2022 : Case report  Germany 31,087

A Report on the First 7 Sequential Patients Treated Within the C-Reactive Protein Apheresis in COVID (CACOV...

DOI :10.12659/AJCR.935263

Am J Case Rep 2022; 23:e935263

19 Jul 2022 : Case report  Saudi Arabia 17,703

Atlantoaxial Subluxation Secondary to SARS-CoV-2 Infection: A Rare Orthopedic Complication from COVID-19

DOI :10.12659/AJCR.936128

Am J Case Rep 2022; 23:e936128

23 Feb 2022 : Case report  USA 17,653

Penile Necrosis Associated with Local Intravenous Injection of Cocaine

DOI :10.12659/AJCR.935250

Am J Case Rep 2022; 23:e935250

Your Privacy

We use cookies to ensure the functionality of our website, to personalize content and advertising, to provide social media features, and to analyze our traffic. If you allow us to do so, we also inform our social media, advertising and analysis partners about your use of our website, You can decise for yourself which categories you you want to deny or allow. Please note that based on your settings not all functionalities of the site are available. View our privacy policy.

American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923